Medication review brief · for the pharmacist
Claire Lindqvist
81 · female · Hypertension, Hypothyroidism, Heart failure, High cholesterol, Anxiety, Osteoporosis
Prepared by Domino · Oct 1, 2026
Summary
3 likely prescribing cascade links. If Sertraline were reviewed, up to 3 downstream medicines might no longer be needed (14 → 10). Anticholinergic burden is 4.
Question 1
Could the trouble sleeping be from the antidepressant? Morning dosing or a different agent may avoid adding a hypnotic.
- Sertraline (Dec 24, 2024) → trouble sleeping → Zopiclone (Jan 28, 2025) · likely 0.99 · consensus
- Sertraline (Dec 24, 2024) → nausea → Dimenhydrinate (Dec 29, 2024) · likely 0.74 · graph-inferred
- Sertraline (Dec 24, 2024) → stomach irritation or bleeding risk → Omeprazole (Mar 1, 2025) · possible 0.42 · graph-inferred
If reviewed: Dimenhydrinate, Zopiclone, Omeprazole; medicines 14 → 10; anticholinergic burden 4 → 1; fall-risk drugs 9 → 6.
Do not stop abruptly
- Sertraline: Taper if changed: stopping suddenly can cause discontinuation symptoms.
- Zopiclone: Taper if changed: stopping suddenly can cause rebound insomnia.
- Omeprazole: Consider a step-down: stopping suddenly can cause rebound acid symptoms.
Question 2
Could high blood sugar be from Atorvastatin?
- Atorvastatin (Aug 19, 2022) → high blood sugar → Insulin glargine (May 18, 2024) · possible 0.42 · graph-inferred
If reviewed: Insulin glargine; medicines 14 → 12; anticholinergic burden 4 → 4; fall-risk drugs 9 → 8.
Question 3
Could the ankle swelling be from the calcium channel blocker? CCB edema does not respond well to diuretics; a dose change or a different antihypertensive may help instead.
- Amlodipine (May 30, 2025) → ankle and leg swelling → Torsemide (Aug 8, 2025) · likely 0.99 · consensus
- Torsemide (Aug 8, 2025) → light-headed on standing → Midodrine (Oct 2, 2025) · possible 0.34 · graph-inferred
If reviewed: no downstream change; medicines 14 → 13; anticholinergic burden 4 → 4; fall-risk drugs 9 → 8.
Medicines
| Medicine | Started | Charted for | Domino |
|---|---|---|---|
| Atorvastatin as prescribed Dr. A. Patel (family doctor) | Aug 19, 2022 | — | Root of a cascade |
| Calcium + vitamin D as prescribed Dr. A. Patel (family doctor) | May 24, 2023 | Osteoporosis | |
| Furosemide as prescribed Dr. K. Osei (cardiology) | Dec 26, 2023 | Heart failure | ACB +1 Beers-listed |
| Empagliflozin as prescribed Dr. K. Osei (cardiology) | Jan 29, 2024 | Heart failure | |
| Lisinopril as prescribed Dr. K. Osei (cardiology) | Feb 19, 2024 | Heart failure | |
| Levothyroxine as prescribed Dr. A. Patel (family doctor) | May 4, 2024 |
Evidence
- McCarthy LM, et al. ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People. Drugs Aging. 2022;39(10):829-840.
- Doherty AS, Lund LC, Moriarty F, et al. Prescribing Cascades Among Older Community-Dwelling Adults: Application of Prescription Sequence Symmetry Analysis to a National Database in Ireland. Ann Fam Med. 2025;23(4):315-324.
- Savage RD, et al. Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension. JAMA Intern Med. 2020;180(5):643-651.
Decision support only. Domino flags patterns in a synthetic record for a clinician to review; it does not diagnose, and it never recommends stopping or changing a medicine. Synthetic data; no real patient.